Gut-directed hypnotherapy for IBS

1. Introduction

Version followed: the Manchester protocol (Whorwell and colleagues, University Hospital of South Manchester; first trial Whorwell et al., Lancet 1984), as described by Gonsalkorale (2006) and Vasant & Whorwell (2019): up to 12 individual weekly sessions with imagery fitted to the patient. The North Carolina protocol (Palsson, 2006; seven fully scripted sessions) is given as the standardised alternative in 4.27. The Amsterdam paediatric protocol (Vlieger et al., 2007; six 50-minute sessions) is mentioned only for orientation. [source: Gonsalkorale 2006; Vasant & Whorwell 2019; ASCH GI Hypnosis Protocols]

Scope and medical frame. Gut-directed (gut-focused) hypnotherapy is clinical hypnosis given by a licensed health professional as an adjunct inside medical care for irritable bowel syndrome (IBS). It comes after a gastroenterologist or physician has made a firm IBS diagnosis and ruled out organic disease. It does not replace diet, medication or medical follow-up. Vasant & Whorwell (2019) say it should not be a standalone treatment and is usually offered after first-line dietary measures and drug treatment have failed. Whorwell's patient leaflet notes that patients who improve may still need occasional bowel medication. Palsson describes it as typically used after standard medical management. Gonsalkorale states plainly that "hypnosis is not a cure for IBS"; the aim is fewer symptoms and a regained sense of control. [source: Vasant & Whorwell 2019; Whorwell IFFGD; Palsson IFFGD 2002; Gonsalkorale 2006]

Core idea of change. IBS symptoms are explained as disordered gut motility, visceral hypersensitivity and the brain misreading or over-reacting to normal gut signals, all made worse by a cycle of anxiety and symptoms. In hypnosis the patient is trained to influence processes that are not normally under conscious control. Suggestions and imagery aimed specifically at the gut (warmth from the hand, a calmly flowing river, a deflating balloon) are rehearsed in session and practised daily at home. Over time the patient comes to experience themselves as being in control of the gut rather than controlled by it. The founders stress that the hypnosis must be gut-specific: general relaxation hypnosis alone is not regarded as sufficient. [source: Gonsalkorale 2006; Walsh 2005 quoting Whorwell; Palsson IFFGD 2002; Riehl ACG 2023]

2. Framework

Format (Manchester). One-to-one sessions with the same therapist, usually weekly, of 30–60 minutes each, for up to 12 sessions over about 3 months. Later sessions can be spaced further apart. A standard or individualised audio recording supports daily home practice. Centres vary, and the optimal number of sessions has not been established. Group and video-call versions exist (see 4.29). [source: Gonsalkorale 2006; Vasant & Whorwell 2019]

Format (North Carolina). Seven scripted sessions of about 30–40 minutes over roughly 3 months, with short home-practice recordings between sessions. [source: ASCH GI Hypnosis Protocols; Palsson IFFGD 2002; Riehl ACG 2023] The spacing is usually every two weeks. Palsson's leaflet gives "weekly or every other week", and the Kinsinger–Palsson adaptation for functional dyspepsia releases one session every 2 weeks with 10–12-minute practice tracks 5 times a week. [source: Kinsinger FD protocol] The exact IBS home-practice schedule in Palsson's 2006 paper is not drawn on here. [uncertain]

Phases (Manchester)

Phase 0. Medical assessment and referral. Goal: confirm the patient is suitable. Content: firm IBS diagnosis (Rome criteria) by a gastroenterologist or physician; organic disease excluded; diet and drug options tried; psychological suitability screened (see 4.1). Move on when: the diagnosis is documented, the patient is still under medical care, and screening shows no exclusion. [source: Vasant & Whorwell 2019; Riehl ACG 2023; Kinsinger FD protocol]
Phase 1. Initial consultation (introductory session). Goal: assessment, education, consent and baseline. Content: clinical history covering symptom pattern, triggers, impact, coping, lifestyle and psychosocial factors; a plain-language explanation of gut physiology and the brain–gut link; exploring the patient's own images of the gut using diagrams; dispelling myths about hypnosis; baseline questionnaires. Move on when: the patient understands the rationale, consents and is motivated to practise daily. [source: Gonsalkorale 2006; Vasant & Whorwell 2019]
Phase 2. Familiarisation (sessions 1–2). Goal: the patient learns to enter and come out of hypnosis comfortably and builds confidence. Content: progressive relaxation induction, deepening (for example a special place), ego-strengthening (tree metaphor), the "calm" cue, and a recording for daily practice. Move on when: gut-directed work usually starts from session 2 or 3. [source: Gonsalkorale 2006] A practical readiness sign is that the patient relaxes reliably, reports no distress in trance and has started home practice. [synthesis]
Phase 3. Gut-directed work (about sessions 2/3–12). Goal: symptom control. Content: the control suggestion, hand warmth on the abdomen, gut imagery matched to the symptom profile, imaginal rehearsal of feared situations, and post-hypnotic suggestions. Anxiety, catastrophising, avoidance and psychosocial stressors are addressed alongside. Each session starts with a weekly symptom-diary review. [source: Gonsalkorale 2006; Vasant & Whorwell 2019]
Review point (around session 6). Response at week 6 predicts response at week 12. Six sessions have not shown the long-term effect of 12, so a partial responder continues. Men and patients with severe symptoms may need more sessions; highly motivated patients who practise a lot may need fewer. [source: Vasant & Whorwell 2019]
Phase 4. Ending and maintenance. Goal: consolidation. Content: review of symptom-diary change, written patient feedback, continued self-hypnosis, and top-up sessions offered as needed. A patient with no improvement by 12 sessions is "very unlikely to derive any benefit" from continuing. [source: Gonsalkorale 2006] Benefits were maintained over 1–5 years in most responders. [source: Whorwell IFFGD; Riehl ACG 2023]

Typical session format. Brief check-in and symptom-diary review (with VAS ratings fed back), then setting the session's focus, then hypnosis (induction, deepening, ego-strengthening, gut-directed suggestions or imagery, post-hypnotic suggestions, re-alerting), then debrief, then a home-practice plan. [source: Gonsalkorale 2006; Riehl ACG 2023 for the generic element order; debrief and plan wording are synthesis]

3. Guiding principles

Adjunct, never replacement. Do not start without a confirmed IBS diagnosis, and keep the patient under medical care with diet and medication in place. [source: Vasant & Whorwell 2019; Whorwell IFFGD]
Gut-specific, not generic. Every session has to include suggestions aimed at gut function and sensation; relaxation alone is not the treatment. [source: Walsh 2005 (Whorwell); Palsson IFFGD 2002]
The patient is in control. Hypnosis is a skill the patient uses; the therapist has no power over them, and they remain aware throughout. Say this explicitly at the start. [source: Palsson IFFGD 2002; Whorwell IFFGD]
Control of the gut is the central theme. Keep returning to the patient "becoming in control of the gut, rather than your gut controlling you". [source: Gonsalkorale 2006; Vasant & Whorwell 2019]
Educate before you hypnotise. A credible physiological explanation (motility, sensitivity, brain–gut signalling, the anxiety–symptom cycle) is part of the treatment. Avoid any implication that symptoms are imaginary. [source: Gonsalkorale 2006; Riehl ACG 2023]
Fit the imagery to the person and the symptom. Use the patient's own images of their gut and adjust the imagery for diarrhoea, constipation, pain or bloating (Manchester). The North Carolina protocol instead uses identical scripts so that every patient gets the same wording. Name which version you are delivering. [source: Vasant & Whorwell 2019; Palsson IFFGD 2002]
Image the solution, not the problem. Have the patient picture a normally working gut. Dwelling on a vivid image of the diseased or painful gut can make symptoms worse. [source: Gonsalkorale 2006]
Daily practice carries the effect. Daily listening plus brief practice during the day and whenever symptoms arise is expected, not optional. [source: Gonsalkorale 2006]
Expect gradual change and setbacks. Prepare the patient for slow progress and a mid-course "blip" from the start. [source: Gonsalkorale 2006; Keefer Psychwire]
Treat the person, not only the bowel. Work on perfectionism, poor boundaries, "should" and "must" self-talk, catastrophising and relationship stress as they come up. [source: Gonsalkorale 2006]
Measure every week and show the patient. Weekly VAS symptom ratings are tracked and shown back to the patient to reinforce progress. [source: Gonsalkorale 2006]
Keep protective warning signals. The North Carolina scripts suggest that real warning sensations still get through while ordinary gut sensations lose their power. In practice, never suggest that new or alarming symptoms should be ignored. [source: ASCH GI Hypnosis Protocols; practical meaning is synthesis]
Work within competence. The therapist should be a licensed health professional with formal clinical-hypnosis training (Palsson suggests about 50+ workshop hours as a benchmark) plus knowledge of GI disorders and the tested protocols. A lay hypnotist certificate does not count. [source: Palsson IFFGD 2002; Keefer Psychwire; Vasant & Whorwell 2019]
Screen out unsuitable patients and stay cautious. Use caution with significant psychopathology, and screen for dissociative disorders, trauma or dissociative symptoms and serious mental illness (see 4.1). [source: Vasant & Whorwell 2019; Keefer Psychwire; Riehl ACG 2023; Kinsinger FD protocol]
No memory work. Gut-directed hypnotherapy is symptom-focused. It never uses age regression or hypnosis to "uncover" causes or memories. [synthesis; consistent with the published protocols, none of which contain regression]

4. Intervention inventory

All example language below is my own illustrative paraphrase, not protocol script text. The Manchester sample script (Gonsalkorale 2006, Appendix 1) and the North Carolina scripts (copyright O. S. Palsson, available to clinicians on request via ibshypnosis.com) should be obtained from their authors. [source: Gonsalkorale 2006; ASCH GI Hypnosis Protocols; Walsh 2005]

4.1 Medical prerequisite check and psychological screening

Purpose: Make sure hypnotherapy is a safe adjunct for this patient before treatment starts.
Steps:
1. Get written confirmation of the IBS diagnosis (Rome criteria) from the referring gastroenterologist or physician, with organic disease excluded. [source: Vasant & Whorwell 2019; Kinsinger FD protocol]
2. Record which diet steps (for example low-FODMAP) and medications have been tried. In Manchester, typical referrals have severe symptoms that persist after first-line diet and drug treatment. [source: Vasant & Whorwell 2019; Riehl ACG 2023]
3. Screen for conditions the sources name as cautions or exclusions: significant psychopathology [Vasant & Whorwell 2019]; dissociative disorders [Keefer Psychwire]; significant trauma or dissociative symptoms [Riehl ACG 2023]; and the serious mental illness exclusions used in the Kinsinger–Palsson trial (schizophrenia or psychosis, eating disorders, OCD, PTSD, dissociative disorders, and cognitive or language barriers to following verbal hypnosis) [Kinsinger FD protocol]. Patients whose psychiatric comorbidity needs comprehensive mental-health treatment should get that first. [source: Riehl ACG 2023]
4. Add a standard risk check: current suicidality, active substance misuse, epilepsy with seizures triggered by deep relaxation or hyperventilation, and severe current depression. Refer these on or treat them first. [synthesis]
5. Agree with the medical team who handles medication changes and new symptoms.
Example language (illustrative): "Before we start, I need to know your gastroenterologist has confirmed this is IBS and that you'll stay under their care. This treatment works alongside your medical care, not instead of it."
Watch for: red-flag symptoms that were never investigated (rectal bleeding, unexplained weight loss, fever, nocturnal diarrhoea, new symptoms after 50, anaemia, family history of bowel cancer or IBD). Send these back to the physician before going further. [synthesis; standard gastroenterology practice, not from the hypnosis sources]

4.2 Initial consultation: history and baseline

Purpose: Build a picture of the patient's symptoms and psychosocial context, form the alliance, and set a baseline.
Steps: Take a history covering symptom pattern (pain, bowel habit, bloating, wind), triggers, impact on work and social life, avoidance, coping, lifestyle, diet history, and psychosocial factors (stress, relationships, perfectionism, self-talk). Administer pre-treatment measures: the Manchester unit used an IBS questionnaire built mostly from visual analogue scales (Francis et al., 1997) plus the HAD scale; the IBS-SS is commonly used, with a 50-point fall counting as clinically meaningful. [source: Gonsalkorale 2006; Vasant & Whorwell 2019] Instruments are named only; obtain them from their publishers.
Example language (illustrative): "Walk me through a typical bad week. What happens to your gut, what do you notice yourself thinking, and what do you stop doing because of it?"
Watch for: avoidance patterns, catastrophic beliefs and stressors to target later. Also watch for psychiatric features that change suitability (see 4.1).

4.3 Psychoeducation: how the gut and brain produce symptoms

Purpose: Give the patient a credible model that makes the hypnotic work make sense and reduces fear.
Steps:
1. Explain basic gut anatomy and physiology in plain language, using diagrams. [source: Vasant & Whorwell 2019]
2. Link the patient's symptoms to disturbed motility (contractions too fast, too slow or uncoordinated), visceral hypersensitivity, and the brain misreading normal gut signals. [source: Gonsalkorale 2006]
3. Describe the brain–gut axis: the brain constantly monitors and adjusts the gut, and stress can make that system over-react. [source: Riehl ACG 2023]
4. Draw the vicious circle: worry about symptoms, then more gut reactivity, then more worry. [source: Gonsalkorale 2006]
5. Use an analogy for a condition that is distressing but not dangerous; Gonsalkorale uses migraine. [source: Gonsalkorale 2006]
Example language (illustrative): "Your gut isn't damaged, but the volume control on its signals is turned up and the muscle rhythm is out of step. The brain and gut talk to each other all the time, and that's the channel we'll be working through."
Watch for: the patient hearing "it's all in your head". Correct this at once: the symptoms are real, physical events in a sensitised system. [synthesis]

4.4 Demystifying hypnosis and informed consent

Purpose: Remove fear, set realistic expectations and get informed consent.
Steps:
1. Ask what the patient already believes about hypnosis and correct the stage-show picture. They stay aware, can stop at any time, and cannot be made to do anything. [source: Palsson IFFGD 2002; Whorwell IFFGD]
2. Present hypnosis as a trained, focused state, similar to deep relaxation or meditation, that helps with processes not normally under conscious control. Gonsalkorale compares this to yogis influencing body functions through meditation. [source: Gonsalkorale 2006; Whorwell IFFGD]
3. Tell the patient what to expect: number of sessions, daily home practice, gradual improvement, possible setbacks, and that up to about a quarter of patients do not respond. [source: Gonsalkorale 2006; Whorwell IFFGD; Keefer Psychwire]
4. Cover risks (temporary emotional discomfort or increased anxiety are the risks named in trial consent) and the right to stop. Record consent. [source: Kinsinger FD protocol]
Example language (illustrative): "You'll hear everything and you can open your eyes whenever you like. It's more like being absorbed in a good film than being asleep. You're learning a skill, and I'm the coach."
Watch for: fear of losing control, religious objections, or expectations of an instant cure. Address each before the first induction.

4.5 Exploring the patient's own gut imagery

Purpose: Find personally meaningful images to use in the gut-directed suggestions.
Steps: Show anatomical diagrams and illustrations. Ask how the patient pictures their gut when symptomatic and when it is working well, including colour, texture, movement and sound. Note symptom-specific metaphors the patient offers. Choose "healthy" images to use; record the "problem" images as ones to avoid. [source: Vasant & Whorwell 2019; Gonsalkorale 2006]
Example language (illustrative): "When your gut is at its worst, what does it look like in your mind? And on a good day, if it had a colour or a movement, what would that be?"
Watch for: images that are frightening or graphic. In Gonsalkorale's case A.C., pain worsened when he pictured a spiked, dimpled stomach. Steer towards images of normal function. [source: Gonsalkorale 2006]

4.6 Pendulum "convincer" (Chevreul's pendulum)

Purpose: Show the patient that thought and imagery can move the body without deliberate effort, which makes the idea of influencing the gut more believable.
Steps: The patient holds a weighted string still above a surface and imagines it swinging in a chosen direction, without moving it on purpose. Point out the small movement that follows, then link it to how imagery can influence the gut. [source: Gonsalkorale 2006 (technique named; step detail is synthesis)]
Example language (illustrative): "Just think about it swinging side to side, without trying to move it. Notice it starting to go along with the thought. That's your mind talking to your muscles below awareness."
Watch for: if nothing moves, frame it neutrally ("everyone experiences this differently"), so that a failed demonstration does not undermine confidence. [synthesis]

4.7 Induction

Purpose: Narrow attention and produce physical relaxation and absorption. [source: Riehl ACG 2023]
Steps (Manchester): A straightforward progressive relaxation induction: guide the patient's attention to each muscle group in turn, slow the breathing, and suggest growing heaviness and comfort. [source: Gonsalkorale 2006; Walsh 2005]
Steps (North Carolina): Eye fixation on a point (the ceiling), then eyelids growing heavy over a count of one to three, then progressive relaxation starting in the hands. Session 1 sets a cue so that in later sessions looking at the ceiling brings heavy eyelids and a quick deep state. [source: ASCH GI Hypnosis Protocols]
Example language (illustrative): "Let your eyes rest on one spot above you… as I count to three your eyelids can grow heavier and close whenever they're ready… and let that ease spread into your hands, as if they were loosening and warming."
Watch for: signs of absorption (slower breathing, facial relaxation, stillness). Also watch for distress signs (agitation, tearfulness, breath-holding, a fixed stare with no response) and, if they appear, pause and re-alert (see 5). [synthesis]

4.8 Deepening

Purpose: Deepen absorption before the therapeutic suggestions.
Steps: Manchester uses a "special place" the patient chooses, imagined in multisensory detail. [source: Gonsalkorale 2006] North Carolina varies the deepener from session to session: walking down a staircase (session 1); a long exhalation with a count to 20 (session 2); turning off "switches" in the nervous system and going down in an elevator (session 4); a sinking sensation (session 5); a cloud drifting downward (session 6). [source: ASCH GI Hypnosis Protocols]
Example language (illustrative): "With each step down, let yourself go twice as deep… and arrive somewhere that's yours, where you feel completely safe. Notice the light, the sounds, the temperature."
Watch for: let the patient choose the special place, and check it is genuinely safe. A beach may be aversive for some patients. [synthesis]

4.9 "Calm" on the out-breath

Purpose: A portable relaxation cue that slows breathing, for use during the day and at symptom onset.
Steps: In hypnosis, the patient silently says "calm" on each out-breath and notices the breathing slow. Give a post-hypnotic suggestion that doing this at any time will bring back the same calm. Practise it awake as well. [source: Gonsalkorale 2006; ASCH GI Hypnosis Protocols]
Example language (illustrative): "Each time you breathe out, let the word calm drift through your mind… and whenever you do this in everyday life, that same steady calm will be there."
Watch for: the patient reporting that they use the cue spontaneously in stressful situations, which shows it is generalising.

4.10 Ego-strengthening (tree metaphor)

Purpose: Build confidence, well-being and a sense of inner resources; mainly used in sessions 1–2 and kept up throughout.
Steps: Suggest general confidence and well-being. Use the tree metaphor: roots reach down into the unconscious as a source of strength; past experiences enrich the soil; worries drift away like falling leaves; the tree grows stronger with each season, as skills grow with practice; and the unconscious regulates body functions. [source: Gonsalkorale 2006; ASCH GI Hypnosis Protocols]
Example language (illustrative): "Picture a strong tree, its roots spreading deep into rich soil… everything you've lived through has fed that soil… and the worries can loosen and fall away like old leaves."
Watch for: low self-worth that makes general praise ring false. Keep the suggestions about the patient's capacity to learn rather than flattering. [synthesis]

4.11 Control suggestion ("surge of control")

Purpose: Install the core idea that the patient can influence their gut.
Steps: After deepening, suggest that the patient can feel a surge of control flowing from the mind down to the gut, and that this control grows with each practice. Repeat the control theme in every gut-directed session and between sessions. [source: Gonsalkorale 2006; Vasant & Whorwell 2019]
Example language (illustrative): "Feel a wave of control moving from your mind down into your abdomen… your mind is learning to take charge of how your gut works, so you're in charge of it rather than it being in charge of you."
Watch for: patients beginning to describe their gut as something they can influence ("I settled it on the train"). That shift is a key marker of progress. [synthesis]

4.12 Hand warmth on the abdomen

Purpose: A tactile anchor that brings comfort and eases pain or spasm, usable in session and in daily life. Particularly used for abdominal pain.
Steps:
1. In hypnosis, say that on a count of three the patient will place one hand on the abdomen, then the other hand on top. [source: Gonsalkorale 2006]
2. Suggest warmth spreading from the hands into the gut, soothing and relaxing the gut muscles and lining. [source: Gonsalkorale 2006; Vasant & Whorwell 2019]
3. Ask for an ideomotor finger lift when the warmth is felt. Gonsalkorale notes that warmth is expected anyway as relaxation increases, which makes success likely. [source: Gonsalkorale 2006]
4. Pair it with the healthy gut image (4.13) and a post-hypnotic suggestion: placing the hands on the abdomen in daily life will bring back the warmth and comfort. [source: Gonsalkorale 2006; ASCH GI Hypnosis Protocols]
Example language (illustrative): "When you're ready, rest a hand on your tummy… notice warmth starting to gather under your palm… and when you feel it, let one finger lift… that warmth is soaking in, easing and calming the whole gut."
Watch for: the finger signal, reported warmth, and pain ratings falling on the diary. For patients with a history of abuse or body-related trauma, touching the abdomen may be distressing. Ask beforehand and offer an alternative such as imagined warmth or a hand resting nearby. [synthesis]

4.13 Imagery of normal gut function (symptom-specific)

Purpose: Have the patient imagine the gut working normally, with imagery chosen for the dominant symptom.
Steps: Use the patient's preferred image from 4.5. Images can be literal (smooth, rhythmic waves of muscle movement) or symbolic. Published Manchester examples:
- Diarrhoea: a rushing, turbulent river slowing to a gentle, steady flow; or a train driver easing the train down to a calm speed. [source: Gonsalkorale 2006; Walsh 2005]
- Constipation: the same river image, with the flow strengthened to an easy, steady current. [source: Vasant & Whorwell 2019]
- Pain: hand warmth (4.12). [source: Vasant & Whorwell 2019]
- Bloating: see 4.14.
- Gonsalkorale also includes relaxing and soothing the gut lining in the sample script. [source: Gonsalkorale 2006]
Example language (illustrative, diarrhoea): "See the river where it's been rushing and churning… and now the banks widen, the water slows, smooth and steady, moving at just the right pace."
Watch for: the image drifting into the problem image (for example spikes, knots or fire). If that happens, gently redirect to the healthy version. [source: Gonsalkorale 2006]

4.14 Deflating balloon for bloating (with diaphragmatic breathing)

Purpose: Reduce bloating and distension.
Steps: In hypnosis, the patient pictures an inflated balloon slowly deflating, sometimes timed with slow diaphragmatic out-breaths. [source: Vasant & Whorwell 2019]
Example language (illustrative): "Imagine a balloon, tight and full… with each slow breath out, a little air escapes… softer, smaller, easing, your abdomen settling flat and comfortable."
Watch for: reported girth or comfort changes on the diary. Combine with breathing retraining (4.22) if the patient breathes from the chest.

4.15 Reducing gut sensitivity (North Carolina themes)

Purpose: Lower visceral hypersensitivity, so that gut signals are felt as milder.
Steps: The North Carolina scripts use protective imagery. Session 1 has a soothing wave passing through the body like a protective coating that lets only comfortable sensation through. Session 3 has a sturdy cabin that keeps out a storm, so sensations that get through are muffled. Session 5 compares bowel sensations to the gentle rocking of a boat that barely registers. Each pairs this with suggestions that the intestines become less sensitive and old triggers lose their power, while genuine warning sensations still come through. [source: ASCH GI Hypnosis Protocols]
Example language (illustrative): "It's as if a soft protective layer has formed along the inside of your gut… everyday sensations reach you only faintly now, like distant sounds through a closed window… while anything that genuinely needs your attention still gets through clearly."
Watch for: reports that ordinary sensations (fullness, gas) no longer trigger alarm. Keep the clause about warning sensations. [synthesis]

4.16 Imaginal rehearsal of feared situations

Purpose: Reduce anticipatory anxiety and avoidance (travel, meetings, eating out, being far from a toilet).
Steps: In hypnosis, the patient pictures themselves in a situation they fear or avoid, staying calm while the gut works normally. They use the calm cue and hand warmth inside the scene. Repeat over sessions and pair with real-life steps. Anchors for calm and reframing support it. [source: Gonsalkorale 2006]
Example language (illustrative): "See yourself on that train journey… settling into your seat, breathing calm on each out-breath… your gut quiet and steady… arriving feeling comfortable and pleased with yourself."
Watch for: the patient actually re-entering avoided situations. If imagining the scene brings strong anxiety, start with an easier one. [synthesis]

4.17 Eating rehearsal

Purpose: Reduce fear and rushing around food.
Steps: The patient rehearses eating slowly and calmly, chewing well, in a relaxed setting. Feared foods are pictured as "friendly". [source: Gonsalkorale 2006] Coordinate with the dietitian: imagery does not override medically advised exclusions or a low-FODMAP plan. [synthesis]
Example language (illustrative): "Picture yourself sitting down to a meal with plenty of time… each mouthful chewed slowly… your stomach receiving the food comfortably and easily."
Watch for: restrictive or disordered eating. Riehl suggests hypnosis may suit patients with a past eating disorder, but the Kinsinger–Palsson trial excluded eating disorders. Assess carefully and do not add food-avoidance suggestions. [source: Riehl ACG 2023; Kinsinger FD protocol] [uncertain]

4.18 Post-hypnotic suggestions

Purpose: Carry the effects of the session into daily life.
Steps: Before re-alerting, suggest that improvement will come gradually and needs patience and persistence; that setbacks are temporary; that the hands on the abdomen plus the healthy image will settle symptoms whenever they are needed; and that the calm cue is always available. [source: Gonsalkorale 2006; ASCH GI Hypnosis Protocols] North Carolina adds that changes continue outside awareness and speed up after the session ends. [source: ASCH GI Hypnosis Protocols]
Example language (illustrative): "Over the coming days and weeks, these changes keep working quietly… if your gut ever grumbles, hands on your tummy and that calm, flowing river will settle it… and if there's an off day, it's just a blip on the way."
Watch for: patients reporting spontaneous use of the cues between sessions.

4.19 Re-alerting

Purpose: Return the patient fully alert and oriented.
Steps: North Carolina usually counts up from 20 to 1 (or retraces the deepening path, such as back up the staircase or elevator) and dissolves the scene. [source: ASCH GI Hypnosis Protocols] Manchester re-alerting is not specified in the sources. [uncertain] Suggest feeling refreshed and alert, with any heaviness gone. [synthesis]
Example language (illustrative): "In a moment I'll count up… with each number, more alert… at the end, eyes open, feeling refreshed, clear-headed, and keeping all the comfort."
Watch for: lingering drowsiness, disorientation or heaviness. Repeat the re-alerting and do not let the patient drive until fully alert. [synthesis]

4.20 Debrief

Purpose: Strengthen the experience, gather information for tailoring, and catch any adverse reactions.
Steps: Ask what the patient noticed (warmth, imagery, depth), which image worked best, and anything uncomfortable. Adjust the imagery for the next session and for the recording. [synthesis; supported by the individualisation principle in Vasant & Whorwell 2019]
Example language (illustrative): "What stood out? Which picture felt most natural, the river or the warmth? Anything you didn't like?"
Watch for: emotional material that came up (see 5).

4.21 Self-hypnosis recordings and daily practice

Purpose: Generalise and consolidate the effects; home practice is central to both protocols.
Steps: Manchester gives a standard recording (copied from a template) or an individualised recording of a session, for daily listening, plus short practice bouts during the day (calm cue, hands on the abdomen) and at symptom onset. [source: Gonsalkorale 2006; Vasant & Whorwell 2019] North Carolina-derived programmes use short tracks (10–12 minutes, about 5 times a week) between the main sessions. Practice can be logged and reminders sent. [source: Kinsinger FD protocol; Palsson IFFGD 2002]
Example language (illustrative): "Listen once a day somewhere you won't be disturbed, never while driving. And use the mini-version, calm breath and hands on your tummy, a few times a day, especially when you feel a twinge."
Watch for: practice frequency. Ask about it every session and connect it to the diary trend. [synthesis]

4.22 Diaphragmatic breathing retraining

Purpose: Counter possible chronic over-breathing and support bloating and relaxation work.
Steps: Teach slow abdominal breathing awake (one hand on the chest, one on the abdomen, with the lower hand moving), then build it into hypnosis and the calm cue. [source: Gonsalkorale 2006; Vasant & Whorwell 2019; hand-placement detail is synthesis]
Example language (illustrative): "Let the breath sink low, so the hand on your tummy rises gently and the top hand barely moves… slow and unhurried."
Watch for: dizziness or tingling from over-effortful breathing. Slow it down and make it smaller. [synthesis]

4.23 Ultradian breaks

Purpose: Build short daily rest periods into the patient's life.
Steps: Encourage brief rests at natural dips in energy during the day, framed as the unconscious doing "essential maintenance work" or inner housekeeping. These can be combined with brief self-hypnosis. [source: Gonsalkorale 2006]
Example language (illustrative): "When you notice that mid-afternoon slump, take ten minutes. Close your eyes, breathe calm, and let your system do its own housekeeping."
Watch for: perfectionist patients who treat rest as failure; link this to 4.24.

4.24 Working with psychosocial factors and thinking styles

Purpose: Address the psychological maintaining factors that slow progress.
Steps: Identify perfectionism, poor boundaries, over-commitment, "should" and "must" self-talk, catastrophising about symptoms, and relationship stress. Interventions named in the Manchester description: reframing self-care as legitimate, assertiveness work, changing self-talk, challenging catastrophic and distorted thinking (Gonsalkorale mentions the Toner et al. cognitive scale as a guide), and addressing relationship emotions directly. These can be done awake or woven into hypnotic suggestion. [source: Gonsalkorale 2006]
Example language (illustrative): "You've said you 'must' never let anyone down. What would happen if you said no to one thing this week, and what would your gut make of that?"
Watch for: if catastrophising, fear-avoidance, worry, intolerance of uncertainty, perfectionism or depression dominate, Keefer suggests CBT may suit better, and the two can be combined. [source: Keefer Psychwire]

4.25 Distancing reframe (embarrassment about gut noises)

Purpose: Reduce shame and self-consciousness about bodily noises and symptoms in public.
Steps: Help the patient view the gut as a separate, somewhat independent organ rather than as their whole self, so that noises are "the gut doing its thing" rather than a personal failing. [source: Gonsalkorale 2006 (case example; wording synthesis)]
Example language (illustrative): "That gurgle is your gut going about its business. It's not you making a statement. Most people around you won't even notice."
Watch for: less social avoidance and less anticipatory dread.

4.26 Weekly symptom diary with feedback

Purpose: Track progress, reinforce gains and guide tailoring.
Steps: At each session, the patient rates upper and lower abdominal pain, bloating, wind, bowel habit and well-being on visual analogue scales. Chart the trend and show it to the patient. At the end of treatment, ask for written feedback on what helped. [source: Gonsalkorale 2006]
Example language (illustrative): "Let's put this week's ratings on the chart. Look, bloating has dropped three weeks running."
Watch for: a midpoint dip (see 5). The week-6 response is the review point. [source: Vasant & Whorwell 2019]

4.27 North Carolina scripted sequence (alternative version)

Purpose: A fully standardised seven-session course for clinicians who prefer a validated script or are working in research or group settings. Obtain the authorised scripts from Palsson (ibshypnosis.com). [source: ASCH GI Hypnosis Protocols; Palsson IFFGD 2002]
Steps (session themes, paraphrased): Every session opens with an eye-fixation induction (4.7) and closes with re-alerting (4.19).
1. A long induction with a staircase descent. A soothing wave like a protective coating; intestines less sensitive; triggers losing power; warning signals preserved; a cue for rapid re-induction next time.
2. A long exhalation and a count to 20. Walking from an empty room to a sensory-rich shore; discomfort becomes as minor as small waves; the intestines settle into a quiet rhythm.
3. A sturdy log cabin and a bed while a storm rages outside; the intestines are protected and any sensations that get through are muffled.
4. Turning off nervous-system "switches" and an elevator descent. A garden and a curving path where comfort spreads through the intestines; the person becomes like the garden; sensitivity falls even outside awareness.
5. A sinking descent. A grassy hill, a pond, a gently rocking boat; bowel sensations barely register.
6. A cloud drifting down. A forest clearing by a waterfall; the breath carries a healthy feeling through the body; about two minutes of silence; comfort persists and a healthy rhythm continues.
7. A count of 1 to 20. A personal place of carefree comfort where discomfort fades; the body grows healthier; changes speed up after leaving; discomfort eventually disappears. [source: ASCH GI Hypnosis Protocols]
Example language: use the licensed scripts. Do not improvise substitutes while claiming fidelity to the protocol.
Watch for: Palsson notes that courses shorter than about 7 sessions may be less effective. [source: Palsson IFFGD 2002]

4.28 Ending, maintenance and top-ups

Purpose: Consolidate gains and prevent relapse.
Steps: Space the final sessions out. Review the diary trend and the pre/post measures. Agree an ongoing self-hypnosis routine and a setback plan (calm cue, hands on the abdomen, recording). Offer top-up sessions as needed. Send a summary to the referring physician. [source: Gonsalkorale 2006; letter to the referrer and setback plan are synthesis]
Example language (illustrative): "You now have the tools. If things flare (stress, illness, travel), go back to daily listening for a couple of weeks. If that isn't enough, book a top-up."
Watch for: abrupt cessation of practice once the patient feels well. Recommend keeping a light maintenance routine. [synthesis]

4.29 Delivery adaptations: group, video-call, digital

Purpose: Widen access.
Steps:
- Group: Effective and cost-effective, but the package has to be generic. Individual therapy suits complex or tertiary cases better. [source: Vasant & Whorwell 2019; Palsson IFFGD 2002; Riehl ACG 2023]
- Video-call (Manchester): 12 sessions with one face-to-face introductory session. [source: Vasant & Whorwell 2019] Agree a safety plan, a private space and an emergency contact before each session. [synthesis]
- Digital therapeutics: These include a prescription app delivering the North Carolina protocol (seven 30-minute sessions over 3 months) and an app based on the Monash protocol (daily 15-minute sessions for 6 weeks). Riehl suggests them when access to a GI psychologist is limited and the patient is motivated, and has no active trauma history or significant psychopathology. Present them as a supplement to the clinician's care. [source: Riehl ACG 2023]
- Children and adolescents: The Manchester protocol (12 weekly sessions) has been used in 8–18-year-olds with severe IBS in a tertiary centre. [source: Vasant et al., Frontline Gastroenterology abstract] Paediatric delivery should be done only by clinicians trained in child hypnosis. [synthesis]
Watch for: practice adherence and unmanaged distress, both of which are harder to spot remotely. [synthesis]

5. Handling problems

Slow progress or no response by the week-6 review. Week-6 response predicts week-12 response, but six sessions are not enough for a lasting effect, so continue a partial responder to 12. Men and patients with severe symptoms may need more sessions. [source: Vasant & Whorwell 2019] Look for stumbling blocks such as unaddressed stress, thinking styles or relationship issues, and work on them (4.24). [source: Gonsalkorale 2006] Check how much home practice is actually happening, and try a different image or sense (touch instead of vision). [synthesis] If there is no improvement by 12 sessions, stop: further sessions are very unlikely to help. [source: Gonsalkorale 2006] Then discuss CBT or other brain–gut therapies with the patient and their physician. [source: Keefer Psychwire; Riehl ACG 2023]
Midpoint setback. This is common around the middle of the course. Frame it in advance and in the moment as a temporary "blip", and point to the diary trend. [source: Gonsalkorale 2006]
Symptoms worsen when the patient attends to the gut. This is often linked to dwelling on a problem image or to hypervigilance. Switch to an image of normal function and avoid vivid problem imagery. [source: Gonsalkorale 2006] Shorten the gut-focus segment and lengthen the comfort and ego-strengthening work. [synthesis]
Low hypnotisability or "nothing happens". Around 15–25% of people are of very low hypnotisability and may benefit less. [source: Palsson IFFGD 2002] There are no conclusive predictors of response, so do not exclude people on that basis. [source: Riehl ACG 2023] Reframe the work as focused relaxation and imagery practice, use the convincer (4.6), and rely more on breathing, awake imaginal rehearsal and cognitive work. [synthesis]
Fear of losing control, or scepticism. Repeat the demystification (4.4), give the patient control of the cues (they decide when to close their eyes, and can open them at any time), and start with short, light inductions. [source: Palsson IFFGD 2002; Whorwell IFFGD; graded approach is synthesis]
Non-adherence to home practice. Ask what gets in the way. Shorten the practice (10–12-minute tracks), tie it to an existing routine, log it, and use reminders. Contacting patients who have stopped practising was built into the Kinsinger–Palsson protocol. [source: Kinsinger FD protocol; problem-solving steps are synthesis]
Emotional upset, abreaction or overwhelm during trance. Trial consent documents name temporary emotional discomfort or increased anxiety as the main risks; the response there is a clinician assessment and, if needed, stopping treatment or referring for counselling. [source: Kinsinger FD protocol] In session: stop the suggestions, speak in a calm, orienting voice, bring the patient back to the safe place or to the room, re-alert fully, ground them (feet on the floor, naming things in the room), and debrief. Do not explore or interpret memories that come up. If trauma material appears, pause the hypnosis and arrange trauma-focused assessment. [synthesis]
Dissociation (spaced out, losing time, depersonalisation). Dissociative disorders are named as a contraindication. [source: Keefer Psychwire; Riehl ACG 2023] If it occurs: re-alert, ground, and do not resume hypnosis until it has been assessed. Switch to awake methods such as CBT or breathing work. [synthesis]
Trauma history, especially abdominal or sexual trauma. Sources advise against hypnosis with significant trauma symptoms. [source: Riehl ACG 2023; Kinsinger FD protocol] For a patient with a stable past history, ask permission before any hand-on-abdomen suggestion and offer alternatives. Never use age regression or hypnosis to find a "cause". [synthesis]
New or changed physical symptoms during treatment. Do not treat them hypnotically. Refer back to the gastroenterologist or GP, especially for red-flag features. [synthesis; consistent with the adjunct framing in Vasant & Whorwell 2019] The North Carolina principle of preserving warning signals applies here. [source: ASCH GI Hypnosis Protocols]
Patient wants to stop medication or diet. Changes go through the physician. Whorwell notes that conventional treatments should not necessarily be stopped even in patients who improve. [source: Whorwell IFFGD]
Patient feels blamed ("you think it's psychological"). This is a common source of rupture. Go back to the physiology model (4.3), validate that the symptoms are real, and present hypnosis as training the brain–gut communication channel, not a sign of mental illness. [source: Gonsalkorale 2006; Riehl ACG 2023; rupture-repair framing is synthesis]
Patient falls asleep in sessions. Sit them more upright, use a lighter induction, and add brief responses during trance (finger signals). Tell them that drifting off still carries some benefit, but that staying aware is better for practice. Do the recordings at a time of day when they are alert. [synthesis]
Depression, anxiety disorder or suicidality emerges. IBS patients with significant psychopathology need caution. [source: Vasant & Whorwell 2019] Assess risk using standard practice, treat the psychiatric disorder or refer for it, and resume gut-directed work only when the patient is stable. [synthesis]
Mismatch with the patient's profile. Keefer favours hypnosis for arousal symptoms, multiple somatic complaints, post-infectious symptoms and hypervigilance, and CBT for catastrophising, fear-avoidance, worry, perfectionism or depression. Combine the two or switch based on the profile and the patient's preference. [source: Keefer Psychwire]
Fidelity drift. Using generic relaxation hypnosis without gut-specific content is not the protocol and is not expected to work as well. Check that each session contains control, hand warmth or imagery, and post-hypnotic gut suggestions. [source: Walsh 2005 (Whorwell); Palsson IFFGD 2002]

Sources

Sources:

Further reading (not drawn on; orientation only):

Whorwell PJ, Prior A, Faragher EB (1984). Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet 2(8414):1232–1234.
Palsson OS (2006). Standardized hypnosis treatment for irritable bowel syndrome: the North Carolina protocol. Int J Clin Exp Hypn 54(1):51–64. [content taken from the ASCH summary] [uncertain]
Vlieger AM et al. (2007). Hypnotherapy for children with functional abdominal pain or IBS. Gastroenterology 133:1430–1436.
Francis CY, Morris J, Whorwell PJ (1997). The irritable bowel severity scoring system. Aliment Pharmacol Ther (instrument named only).
Knowles SR, Keefer L, Mikocka-Walus A (eds). Psychogastroenterology for Adults (Routledge), recommended by Keefer for further reading.

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